What are the initial management orders for diabetic ketoacidosis (DKA)?

From the Guidelines

The initial management of diabetic ketoacidosis (DKA) requires prompt fluid resuscitation, insulin therapy, electrolyte replacement, and addressing the underlying cause, with the most recent guidelines from 2024 1 emphasizing individualization of treatment based on careful clinical and laboratory assessment. The management goals include restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis.

• Begin with aggressive intravenous fluid resuscitation using 0.9% normal saline at 15-20 mL/kg/hr (typically 1-1.5 L) in the first hour, then adjust to 250-500 mL/hr based on hemodynamic status.
• Start continuous intravenous insulin infusion at 0.1 units/kg/hr after the initial fluid bolus, as recommended by recent studies 1.
• Monitor blood glucose hourly, aiming for a decrease of 50-75 mg/dL per hour.
• When glucose reaches 200-250 mg/dL, add dextrose to IV fluids (D5 or D10) while continuing insulin to clear ketones.
• Replace potassium when levels are below 5.3 mEq/L and urine output is adequate, typically at 20-30 mEq per liter of IV fluid.
• Monitor electrolytes (sodium, potassium, chloride, bicarbonate) every 2-4 hours initially.
• Check for and treat precipitating factors such as infection, medication non-adherence, or myocardial infarction.
• Continuous clinical reassessment is essential, including vital signs, mental status, fluid balance, and laboratory parameters. This approach addresses the fundamental pathophysiology of DKA: dehydration, insulin deficiency, and metabolic acidosis, and is supported by the most recent and highest quality evidence 1.

From the Research

Initial Management Orders for Diabetic Ketoacidosis (DKA)

The initial management of DKA involves several key steps to restore optimal volume status, reverse acidosis, reduce serum glucose levels, and replace specific electrolytes. The mainstay of treatment for DKA is appropriate fluid and insulin therapy.

• Fluid resuscitation: Isotonic normal saline remains the standard for initial fluid resuscitation, though balanced solutions have been shown to have faster DKA resolution 2.
• Insulin therapy: Current guidelines recommend using continuous IV insulin for DKA management after fluid status has been restored and potassium levels have been achieved 2. Low-dose intravenous infusion is now the accepted mode of insulin delivery for patients with this condition 3, 4.
• Electrolyte replacement: Potassium replacement is almost always necessary, often requiring massive amounts of this ion due to the total body depletion seen with the development of ketoacidosis 3. Phosphate replacement may be needed if serum levels fall toward the lower limits of normal values 3.
• Prevention of cerebral edema: Rapid overcorrection of hyperglycemia with fluids and insulin can lead to cerebral edema, seizures, and death. Clinicians should be aware of risk factors and preventive strategies for cerebral edema 2.
• Airway management: For impending respiratory failure, intubation and mechanical ventilation, with monitoring and management of acid-base and fluid status, are recommended 2.
• Use of sodium bicarbonate: The use of sodium bicarbonate is discouraged due to the potential for worsening ketosis, hypokalemia, and risk of cerebral edema. However, IV sodium bicarbonate can be considered if the serum pH falls below 6.9, or when serum pH is less than 7.2 and/or serum bicarbonate levels are below 10 mEq/L, pre-and post-intubation, to prevent metabolic acidosis and hemodynamic collapse that occurs from apnea during intubation 2, 3.

Subcutaneous Insulin

Subcutaneous regular insulin administered every 4 hours is an effective and safe alternative for the insulin treatment of DKA with pH > 7.0 in children 5. This treatment has the potential to simplify insulin administration when compared to either intravenous regular insulin or q1-2 hour subcutaneous rapid insulin and reduce both patient inconvenience and admission costs.

Protocol Implementation

Implementation of a standardized DKA management protocol using a 2-bag intravenous fluid system can decrease the duration of intravenous insulin therapy and the number of adjustments to insulin drip rate without increasing the incidence of adverse events 6.